Paul Ruffino, 55, is an uninsured Libertarian and conflicted over what role the government should play in remaking the health insurance system.
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Paul Ruffino, 55, is an uninsured Libertarian and conflicted over what role the government should play in remaking the health insurance system.

Sarah Varney/for NPR

Here, just a few miles from the entrance to Yosemite National Park, is the Sweetwater Steakhouse, a local watering hole where no one is shy about their opinions of President Obama's signature initiative.

"Obamacare is absolutely horrible, horrible, horrible," Joe Stern, owner of a local water-conditioning company, says as he sips a glass of pinot noir. "It should be struck down immediately."

By 5 o'clock on most weekday evenings, the Sweetwater bar is hopping, and locals, like Stern, stop by to josh and jest. Stern is a registered Republican. He's 66 years old and covered by Medicare, a program Stern says he is thankful for. Before he qualified for the federal program, Stern, who is single, used to pay $670 a month for insurance — more than $8,000 a year.

"I thought it was pretty brutal," he says, "but I was still against Obamacare by far."

Oakhurst caps the eastern end of Madera County, a largely conservative and agricultural region where unemployment runs stubbornly high, at 14.7 percent, and 32 percent of people have no health insurance.

By and large, conservative voters in the county despise the federal health law's mandate that all Americans have health coverage, and many suspect the health insurance system isn't really all that broken.

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Reflecting a common sentiment, Stern says, "I don't know of anyone that was left on the street to bleed to death. I don't know anyone that is really left out."

It's not that Stern doesn't know people who don't have insurance. He cheerfully introduces his friend, Mary Westover, who is sitting next to him at the bar. Westover is a registered Republican and a self-employed artist and businesswoman who says she can't afford health insurance. She's been uninsured for 17 years — she hasn't had a pap smear in all that time — and is among the 13 percent of Americans who are uninsured and opposed to the health law.

Westover, too, is against the individual mandate, but wasn't aware the federal government would give subsidies to people like her — whose incomes are below 400 percent of the federal poverty level — to buy a policy. That's once that part of the law kicks in, in 2014.

"If it were subsidized, if it were made, you know, manageable, I would want that," she says, adding that she doesn't know how people who can afford it "can sit there and say that we shouldn't have that — because there are a lot more of us, than them."

Republican Doug Macaulay, who has been selling health insurance in the small town of Oakhurst, Calif., for nearly three decades, says he has heard everyone's opinion of the Affordable Care Act.
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Republican Doug Macaulay, who has been selling health insurance in the small town of Oakhurst, Calif., for nearly three decades, says he has heard everyone's opinion of the Affordable Care Act.

Sarah Varney/for NPR

Although many here in Madera County say they want the U.S. Supreme Court to throw the federal law — and all of its big government mandates — out, they are struggling to reconcile their political ideologies with the basic need for health insurance and protection from financial calamity.

Paul Ruffino, the manager of Chateau du Sureau, a five-star, luxury inn overlooking the mountains of Yosemite, is uninsured for the first time in his life.

"It's probably when I need it the most," he says, sitting in the inn's salon, with its fresco-painted ceilings and roaring fire.

Ruffino says the health insurance policies he's looked at are expensive and won't cover his pre-existing conditions. Still, he says it was his decision to leave a previous job in Southern California that came with insurance and move to Oakhurst. As a Libertarian (the GOP is too liberal, he says), he doesn't think he should have help in getting insurance: "Do I make the government responsible for my choices? I made the choice. I knew beforehand."

Ruffino seems torn between his unsparing self-reliance and a sense that the insurance industry is unfair. He thinks insurance companies should not be allowed to pick out only the healthy and leave guys like him behind. He says there is a role for government in setting some of the rules, but he's uncertain just how far he wants to go.

"Does there come a time when government has to get involved and at what levels? But when you are distrustful of the system in whole it makes it difficult," he says. "I go back and forth. I ping-pong on this issue all the time."

It doesn't surprise Oakhurst insurance agent Doug Macaulay that many people are torn.

Macaulay, who is also Republican, says people get mad at the insurance companies, but they don't see "Obamacare," as they derisively call it, as the answer: "You're complaining over here that you don't have health insurance and you can't buy it. And over here [the government is] trying to provide you with it but that's the worst thing ever. So there seems to be a disconnect in the thinking there."

Shots is the online channel for health stories from the NPR Science Desk. We report on news that can make a difference for your health and show how policy shapes our health choices. Look to Shots for the latest on research and medical treatments, as well as the business side of health. Your hosts are Scott Hensley and Nancy Shute. You can reach the Shots team via our contact form.